Avon & Wiltshire NHS Trust - Phase Two

Avon and Wiltshire Mental Health Partnership NHS Trust has completed phase one of their involvement in National Workforces Projects Team working, Handover and Escalation pilot project. As outlined in the final report, one of the main conclusions was that changes to the working practices of one staff group cannot be made in isolation, and therefore the intention is to continue to redesign the workforce with the development of a new functional model spanning the inpatient units and community teams.

The model has been developed in order to ensure a whole system integrated approach to new ways of working, drawing together all initiatives at a local and Trust wide level. It has been recognised that altering the medical roles alone is not effective, therefore the entire clinical service is being reviewed, and within that the roles of Junior Doctors will be completely reviewed.

Phase one of the project resulted in a number of outputs – Out of Hours protocol, advanced skills training for nursing staff, PGD development and acute care pathway development. This review was centred on the inpatient units and resulted in a reduction in the risk of junior doctors exceeding the 48 hour limit due to changes in practice, particularly with reference to out of hours calls. As a result of the project the Trust determined that working practice could be further enhanced by introducing a functional model and is now redesigning the community service in order to facilitate the introduction of this approach. It is felt that the functional model will impact on the WTD by streamlining the admission process, thus minimising further the on call responsibilities of junior doctors. Juniors will be allocated to either inpatient units or community services on a rotational basis.

As an overview, this redesigned clinical service will look to introduce a functional model where Green Lane Hospital will have:

1. Specialist Consultant Psychiatrists working across the inpatient wards at Green Lane Hospital and providing medical input to the CAHTT (Crisis and Home Treatment Team) - contributing to crisis assessments, alternative home treatment for the seriously acutely ill, and facilitation of early discharge from hospital.
2. Community Consultant Psychiatrists to provide Community based services in conjunction with Community Mental Health Teams – managing non crisis referrals from primary care, offering ongoing treatment to those with time-limited conditions (before referral back to primary care), managing patients with long term but less complex or severe conditions and liaising/ interfacing with primary care services.
3. Consultant input into the ACT/rehabilitation team which cares for those with more complex, enduring needs

Junior Doctors will be allocated to each element of the service and we are confident that this new model will improve Junior Doctors’ training experience and reduce risk of non compliance with EWTD.

The community mental health teams have been involved in considering the implications of a functional medical model on their operations and a redesign of the service has been welcomed. The project plan has been developed and it looks at all aspects of the service and is likely to result in changes to team boundaries, operating policies and workforce. The capacity and capabilities of the workforce will need to be mapped as part of the project.

The ‘products’ generated by this work will include a complete care pathway integrating acute inpatient and community services and protocols around the interface between teams, criteria for the gatekeeping role and a performance management process.

Outline of project Scope: To continue the work of phase one around the inpatient pathway and to extend this to include the community, team interfaces and the gate keeping function of the crisis team. The gatekeeping role is considered key to ensuring the most efficient and effective use of medical resources thus achieving compliance with the EWTD.

Aims:

• To agree a complete care pathway (design, test, refine, roll out)
• To use the care pathway to create efficient processes that will deliver high quality, evidence based care in a seamless fashion using tools which can be translated into other service areas both inside and outside the trust.

Objectives:

• Team commitment to an agreed complete care pathway
• Process mapping work extended to team interfaces.
• Use the process mapping work to create user-friendly systems to improve working patterns and patient experience.
• To create a process for performance monitoring the gatekeeping and facilitated discharge functions of the crisis team.
• Ensuring that systems that are set up are standardised and transferable to other settings and geographical areas.
• Ensure the agreed pathway facilitates the most efficient use of junior doctors time and training experience within inpatient, crisis and community teams.